严重烧伤后深静脉导管相关感染并发颅内多发性脓肿一例.doc

严重烧伤后深静脉导管相关感染并发颅内多发性脓肿一例
A Case of Cerebral Multiple Abscess Occuring With Deep Vein Catheter Related Infection After Severely Burnt

患者男，36岁，因全身火焰烧伤于伤后3h入院。入院时检查: T36.1℃, P96次/min, R 22次/min, 患者一般情况可，神志清楚，呼吸平顺，烧伤创面分布于头面、颈，躯干及四肢，创面基底大部分呈黄白色。入院诊断: ①烧伤总面积35% , 浅II度15%,深II度20%。入院后行右侧股静脉穿刺置管常规液体复苏、创面清创，头面部暴露,四肢及躯干创面外用1%磺胺嘧啶银霜包扎等治疗。入院后20h,患者面颈部、双前臂肿胀明显,自诉喉头有异物感及双手指麻木等不适,遂于局麻下行气管切开,双上肢烧伤皮肤及浅筋膜切开减压术,随后病情平稳。伤后5d在静脉全麻下行“双上肢、左小腿深II度创面15%削痂、自体网状皮移植术”，术后应用头孢哌酮+依替米星抗感染,面部深II度创面,躯干等部位创面继续外用1%磺胺嘧啶银霜隔日换药,创面分泌物未培养出细菌,术后5d,削痂植皮创面换药,皮片成活良好，伤后14d拔除气管套管，拔管后患者呼吸平顺，病情稳定，除右下腹及左足背约1%深II度创面未愈外,其余创面均愈合。治疗过程中,伤后11d开始,患者出现高热,最高达40.1℃,外周血白细胞计数达20.1×109/L,中心粒76%,调整抗生素为美洛西林+依替米星二联抗感染,2d后, 外周血白细胞计数下降至11.4×109/L, 中心粒细胞86%,体温仍有波动,最高为38.9℃, 胸部X-线检查未见双肺有异常改变。伤后15d再次出现寒战、高热，考虑有金黄色葡萄球菌感染可能,拔除右侧股静脉导管并送细菌培养, 调整抗菌素为稳可信500mgq6h静脉点滴, 再次送检创面分泌物细菌培养及血培养。3d后,静脉导管、创面分泌物及血细菌培养均为耐甲氧西林金黄色葡萄球菌生长（MRSA），体外药物敏感试验对万古酶素敏感，继续静滴稳可信,患者体温有所下降，但渐渐出现神情淡漠、懒言及肢体乏力等症状, 静滴稳可信6d后，出现左上肢肌力减退（III级），行颅脑MR检查示：右侧小脑半球及颞叶、额叶见多发片状长T1、T2信号影，境界模糊，压水序列像上呈高信号，增强扫描见明显环行强化或不完全的环形强化，局部脑沟、裂变窄，最大病灶位于右侧颞叶，大小约3cm×2.8cm，两侧大脑，左侧小脑尚可见散在小斑点样强化灶。提示两侧大脑、小脑多发性感染灶，部分脓肿形成，结合临床诊断为烧伤后颅内多发性MRSA感染，部分脓肿形成。转神经内科继续稳可信并加用磷霉素钠抗感染，甘露醇脱水降颅压等治疗，一周后，因脓肿破裂出血死亡。
译文： The patient, male, 36 years old, was sent to hospital 3 hours after he was burnt by flame all over his body.Examination on admission: 36.1T℃, P96 times/min, R 22 times/min, patient was in ordinary condition with conscious mind and smooth breath. The burnt wound spreads in head, neck, body and 4 limbs.The base of burnt wound was mostly yellowish white.Diagnosis on admission: ①Total burnt area 35%, II degree superficial burn 15%, II degree deep burn 20%. After admission, the patient received treatment of indwelling catheter by right femoral vein puncture conventional fluid resuscitation, wound debridement, head and face exposure, 4 limbs and body wound bound up externally with 1% density sulfadiazine silver frost, etc. 20 hours after admission, patient’s face, neck and both forearms were obviously swelling. He complained there was malaise feeling of foreign-body sensation in throat and numbness in both hands fingers. So tracheotomy, burnt skin of both arms and superficial fascia incision release were carried out. Then the patient’s condition was improving. 5 days after injury, 15% of both arms, left calf II degree deep burnt wound scab excision and meshed autogenous skin transplantation were carried out under intravenous anaesthesia. After operation, cefoperazone and etimicin were used to prevent infection, and 1% density sulfadiazine silver frost was still applied externally in II degree deep burnt face wound and body wound which would be refreshed on alternate days. Bacteria was not cultured from wound secretion. 5 days after operation, medicine was refreshed for scab excision and skin grafting wound.The skin graft flap was well developed. 14 days after injury trachea cannulas was pulled off and the patient could breathe smoothly and condition was stable. All wound areas were healed except 1% of II degree deep burnt wound in right lower abdomen and left dorsalis pedis.During treatment, since 11 days after injury, patient was found have high fever, and the highest temperature could reach 40.1℃,the number of peripherial leucocytes amounted to 20.1×109/L with centriole 76%. The adjusting antibiotic was 2-drug mezlocillin and etimicin anti-infective. 2 days later, the number of peripherial leucocyte dropped to 11.4×109/L with centriole 86%. Body temperature of patient still had fluctuation and the highest temperature reached 38.9℃. Chest X-ray inspection found no abnormal changes in both lungs.15 days after injury, patient was found have again shivering and high fever. Considering there was possibility of staphylococcus aureus infection, the right femoral vein catheter was pulled off and usd for bacteria culture, antibiotic was adjusted into vincocin 500mgq6h intravenous infusion, and the wound secretion was used again for bacteria culture and blood culture.3 days later, vein catheter, wound secretion and blood bacteria culture were all methicillin resistant staphylococcus aureus grow (MRSA), being sensitive to vancomycin through vitro drug sensitivity test. Continue to intravenously drippinginject with vancomycin, patient body temperature dropped to some extent, but gradually appeared symptoms of looking indifference, lazy speaking, and limbs weakness. After 6 days of intravenous infusion of vancomycin, left upper extremity muscle strength weakness was found ( degree III). Craniocerebral inspection was made and indicated: there were multiple flake style T1, T2 signal density with obscure realm in right cerebella hemisphere, temporal lobe and front lobe. Pressurized water sequence image showed high signal, enhanced scan showed evident ring enhancement or incomplete enhancement, and partial cerebral sulcus and cerebral fissure got narrowed. The biggest focus lied in right temporal lobe and the size was about 3cm×2.8cm, and there were still seperated tiny specks of focus in both sides of brain and left cerebella.It showed there was multiple infection focus in both sides of brain and cerebella and some abscess had formed. Combined with clinic data it was diagnosed to be cerebral multiple MRSA infection after burnt and some abscess had formed.Patient was transferred to neurology department, vancomycin continued to be used and combined with fosfomycin sodium to prevent infection with treatment of mannitol dehydrating to reduce cerebral pressure. One week later patient died of abscess rupture.
讨论：
烧伤后感染等并发症至今仍然是烧伤治疗中棘手的问题之一，特别是多重耐药细菌的感染并发症。烧伤后并发颅内感染虽然较少见，但仍有病例报道[1]，多见于儿童,成人也可发生。感染多为血源播散性,与严重烧伤后机体免疫功能低下易发生侵袭性感染有关，也有医源性因素如深静脉导管的相关性感染所致[2]感染的病源菌多与病区优势致病菌一致，如铜绿假单胞菌、金黄色葡萄球菌等。烧伤后由耐甲氧西林的金黄色葡萄球菌（MRSA）所致的颅内感染较为少见，1992年Suzuki 报道一例[3]。由于烧伤后颅内感染早期多与侵袭性感染症状相似，易漏诊，脑膜炎症后，对MRSA敏感的抗菌素如万古霉素等难以透过血脑屏障，给治疗带来很大困难。本例烧伤面积为35%，烧伤创面主要分布在头面部和四肢暴露部位，因常用的外周静穿刺部位均被烧伤而选择了深静脉置管。在伤后2周创面基本愈合时，突发高热、白细胞增高等全身感染表现，创面分泌物、深静脉导管及血培养均培养出MRSA，结合病程、临床表现和各项检查，可诊断颅内多发性脓肿源于右股静脉导管的MRSA相关感染。尽管选用了敏感抗菌素，但万古霉素难以透过血脑屏障，局部组织难以达到有效的杀菌浓度，最终治疗失败。烧伤后留置深静脉导管，一旦发生导管感染和化脓性栓塞性静脉炎，会给后续的病灶清除术带来困难，因此，有作者认为，留置导管时应尽量避免使用深静脉[4]。但在临床实际工作中，对大面积深度烧伤病例，留置深静脉导管有时在所难免，但要尽可能选择血流速度快，不易形成血栓的部位，如颈内静脉、锁骨下静脉等。导管留置超过7日以上,特别是股静脉部位,导管相关性感染的机率会明显增加[5] 。因此,达到治疗目的后,应尽早拔除,需要较长时间使用的,应定期重新穿刺,更换导管。本病例入院时因四肢常用的外周静脉穿刺部位皮肤被烧伤,而选用了右股静脉穿刺置管,但未能及时更换,且留置时间过长,增加了发生导管相关感染的机会,应特别引起重视。此外,留置深静脉导管后,还应加强插管部位皮肤的护理，保持局部干燥、清洁，导管内使用抗凝剂，采用抗生素锁技术等也能有效地减少深静脉导管相关性感染的发生。
译文：
Discussion:
Complications such as infections after burnt are still one of the thorny problems in burn treatment to date, especially the complication caused by multiple drug-resistant bacteria.Though cerebral infection superinduced after burnt is seldom, there are still medical cases reported. It is more common in children, also possible in the adult. Most infections are blood disseminated which are related to lower immune function after burnt which becomes susceptible to infection. There are also iatrogenic factors such as deep vein catheters related infection. The infected pathogens are mostly the same as the wound patch advantage pathogens, such as the pseudomonas aeruginosa, staphylococcus aureus. Cerebral infection caused by methicillin-resistant staphylococcus aureus after burnt is scarce. In 1992 in Suzuki one case was reported. Becouse in the early period the symptoms of cerebral infection after burnt are similar to those of invasive infections, missed diagnosis tends to happen. After meningococcal disease, antibiotics sensitive to MRSA such as vancomycin are difficult to pass the blood-brain barrier which causes big difficulties to treatment.In this case the burnt area is 35%, burnt wound mainly spreads in the exposed parts of head, face, and 4 limbs. Becourse commonly used peripheral vein puncture parts were all burnt, the deep vein indwelling was selected. When the wound area was basically healed 2 weeks after injury, symptoms of systemic infection such as high fever and increased leucocytes suddenly occurred. Wound secretion, deep vein catheters and blood culture all cultured out MRSA. Combined with disease course, clinic features and variety of examinations, it can be diagnosed that multiple cerebral abscess was caused by MRSA in right femoral vein catheter related infections. Although sensitive antibiotics were used, vancomycin was difficult to pass blood-brain barrier, and local tissue was difficult to achieve effective bactericidal concentration which leaded to treatment failure finally.The deep vein catheter remained in body after burnt, if once infected and suppurative thrombophlebitis happened, will bring difficulties to the subsequent disease focus debridement surgery. So some author thinks it should avoid employing deep vein while indwelling catheters as much as possible. But in practical clinic work, in extensive deep burn medical case, deep vein catheter indwelling is sometimes inevitable, and the place where blood circulates fast and thrombus does not easily form should be selected, such as the jugular vein and subclavian vein. If catheter remains more than 7 days especially in the place of femola vein, the chance of catheter related infection will be increased apperantly. Therefore the catheter should be pulled off as early as possible once the therapeutic purposes are achieved. If long time use is necessary, it should be re-punctured at regular intervals and renew the catheter.In this case, becourse the commonly used peripheral vein puncture parts of 4 limbs are burnt on admission, the right fomela vein puncture indwelling was selected. But catheter was not renewed timely, and it remained for too long a time which increased the chance of catheter related infection. This should be paid special attention to.In addition, after deep vein catheter is remained, intensive care should be given to the skin of indwelling parts and keep dry and clean locally. Anticoagulation agent should be used in catheter, and the antibiotic lock technology can also reduce the chance of deep vein catheter related infection effectively.

参考文献：

1．林源.小儿大面积烧伤晚期并发脑脓肿一例.中华烧伤外科杂志,2001,17:59
2．Reper P, Van Der Rest P, Creemers A,et al. Medical treatment of a central vein suppurative thrombosis with cerebral metastatic abscesses in a burned child. Burns . 2001, 27:662-663.
3．Suzuki T, Ueki I, Isago T,et al. Multiple brain abscesses complicating treatment of a severe burn injury: an unusual case report. J Burn Care Rehabil. 1992,13:446-450.
4．陈玉林.关于烧伤感染防治的几点思考.中华烧伤杂志,2006,22:81-82
5．Darouiche RO, Raad Ⅱ, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med, 1999, 340:1-8

译文：

References:

1. Lin Yuan: One Case of Advanced Stage of Extensive Burn in Children Complicated With Cerebral Abscess. Journal of China Burn Surgery. 2001, 17:59

2. Reper P, Van Der Rest P, Creemers A,et al. Medical Treatment of A Central Vein Suppurative Thrombosis With Cerebral Metastatic Abscesses In A Burned Child. Burns . 2001, 27:662-663.

3. Suzuki T, Ueki I, Isago T,et al. Multiple Brain Abscesses Complicating Treatment of A Severe Burn Injury: An Unusual Case Report. J Burn Care Rehabil. 1992,13:446-450.

4. Chen Yulin.Reflections of Burn Infection Prevention. Journal of China Burn Surgery,2006,22:81-82

5. Darouiche RO, Raad Ⅱ, Heard SO, et al. A comparison of two Antimicrobial-Impregnated Central Venous Catheters. Catheter Study Group. N Engl J Med, 1999, 340:1-8